How to Answer Discharge Summary Note Questions (Complete Guide)

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Original Question

Discharge Summary Note: The patient is a 91-year-old female, who presented one day ago with PNEUMONIA. ADMISSION DIAGNOSES: 1. Pneumonia DISCHARGE DIAGNOSES: 1. Pneumonia, bacterial 2. Hypoxia. HOSPITAL COURSE: This very independent 91-year old had struggled with cough, fevers, weakness, and chills for two days prior to admission. She arrived at the office and she was transported by ambulance as a direct admission to the floor. Dr. Florenz, pulmonologist was consulted. Patient quickly responded to IV fluids, antibiotics and acetaminophen for the fever. In 24 hours there has been marked improvement. Patient remains weak and has agreed to pulmonary rehab for about a week to regain her strength. I spoke with one of her daughters today about the fact that she generally lives independently at the Brooke and she may need assisted living along with oxygen for a period of time rather than going back to independent living. Her daughter while arrive for patient’s DC from rehab facility and plans to stay with her for a while. PHYSICAL EXAM: VITAL SIGNS: Temperature is now below 99F oral; blood pressure is within normal ranges for this pt at 122/68, pulse is in the 60s. She is 95% on 2L of oxygen. HEART: Regular rate and rhythm without murmur, gallop or rub. LUNGS: Continues to reveal expiratory wheezing throughout. She does have significant rhonchi on the right mid base. She does have a productive cough. ABDOMEN: Soft and nontender. Her bowel sounds x4 are normoactive. NEUROLOGIC: She is alert and oriented x3. Her pupils are equal and reactive. Normal head and facial muscle strength. Intact range of motion with regard to shoulders, elbows, wrists, and fingers. Grip strengths are equal bilaterally. ALLERGIES: PENICILLIN. DISCHARGE PLAN: 1. If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room. 2. Discharge patient from hospital to rehab facility, South Side Rehabilitation, for pulmonary rehab and care for 1 week, then discharge home. 3. Doctor X will take over patient’s care while in rehab. 4. Repeat CXR in one month. 5. Rehab facility to arrange for portable oxygen when patient discharged home. 6. Rehab facility to determine patient’s need for home health care and/or rehab at home. PATIENT CONDITION AT DISCHARGE: Stable MEDICATIONS ON DISCHARGE: to be continued in rehab facility and then at home 1. Prednisone tapering dose 40 mg PO daily for three days, then 30 mg PO daily for three days, then 20 mg PO daily for three days, then 10 mg PO daily for three days, and 5 mg PO daily for two days. 2. Levaquin 750 mg PO daily for 5 more days. 3. Levothyroxine 0.1mg PO every am 4. Acetaminophen 500mg PO every 4 hours PRN 5. Benadryl 25mg PO every 4 hours PRN 6. Albuterol inhaler 2 puffs every 2-4 hours PRN for shortness of breath. 7. Oxygen 2-4L via NC for shortness of breath. FOLLOW-UP APPOINTMENT: See me in my office in 2 weeks. CASE 4 PATIENT NAME: Mei Zheng PATIENT TYPE (highlight the appropriate patient type for this case) : IP OP ED PHYSICIAN Practice If Inpatient, what is the patient’s Principal Diagnosis in words, followed by the ICD-10 code? If inpatient, what is/are the patient’s secondary diagnosis(es) (if any) in words, followed by the corresponding ICD code(s). You are responsible for knowing and understanding the definition of a secondary diagnosis that needs to be coded as well as sequencing guidelines. What is/are the corresponding ICD- code(s) for the diagnosis(es) If inpatient, what is the patient’s principal procedurein words, followed by the ICD code? If inpatient, what is/are the patient’s secondary procedure(s)(if any) in words, followed by the corresponding ICD code(s)? You are responsible for knowing and understanding the definition of a secondary procedures that need to be coded as well as sequencing guidelines. If Outpatient/ED/Physician practice what is the patient’s Primary Diagnosis in words, followed by the ICD code? Are there any secondary diagnosis(es) (if any) in words that should be coded? You are responsible for knowing and understanding the definition of a secondary diagnosis that needs to be coded as well as sequencing guidelines. What is/are the corresponding ICD code(s) for the diagnosis(es). Are there any procedures that need to be coded; if so, code them in the proper order, using the proper coding system. TYPE, IN PROPER ORDER, THE DIAGNOSIS AND PROCEDURE CODE(s) for CASE 4 are:

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